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Analytical

Methods
www.rsc.org/methods Volume 5 | Number 15 | 7 August 2013 | Pages 36033762

ISSN 1759-9660

CRITICAL REVIEW
Termeh Ahmadraji and Anthony J. Killard
The evolution of selective analyses of HDL and LDL cholesterol in clinical and
point of care testing 1759-9660(2013)5:15;1-J
Analytical
Methods
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The evolution of selective analyses of HDL and LDL


cholesterol in clinical and point of care testing
Cite this: Anal. Methods, 2013, 5, 3612

Termeh Ahmadraji and Anthony J. Killard*


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Cardiovascular disease is a leading cause of death worldwide and is caused by the build up of
atherosclerotic plaques in the vasculature. It is now well established that the formation of these plaques
is closely related to levels of both high density lipoprotein (HDL) and low density lipoprotein (LDL)
cholesterol. Thus, the importance of the eective measurement of these is critical for the improved
diagnosis and management of atherosclerosis. This review discusses the emergence of methodologies
for the selective determination of both LDL and HDL cholesterol. It begins with an explanation of the
rst methodologies based on ultracentrifugation and precipitation techniques, the development of
Received 30th April 2013
Accepted 20th May 2013
reference methods, through to the emergence of methodologies suitable for routine laboratory use,
followed by the development of professional use, point of care technologies. Finally, the current status
DOI: 10.1039/c3ay40715b
of selective tests for cholesterol based on biosensor methodologies is reviewed and the potential for
www.rsc.org/methods application in consumer diagnostics is discussed.

Introduction levels. As a result, cholesterol has become one of the main


parameters which are measured in routine clinical laboratory
Coronary artery disease is the number one cause of death in all testing, accounting for an increase in demand for cholesterol
developed countries.1 In the 1980s, public concern over the risks testing technology in the last few years.24 Atherosclerosis is a
of high blood cholesterol levels began to rise. Since then, several condition in which arteries become blocked partly due to the
studies have demonstrated the increased risk of cardiovascular accumulation of cholesterol. When cholesterol deposits on the
diseases including arteriosclerosis due to high cholesterol walls of arteries, plaques form which may lead to blockages and
interruption of the circulation, causing angina and myocardial
infarction, with their associated morbidity and mortality. Some
Centre for Research in Biosciences (CRIB), Department of Applied Sciences, University
plaques can burst which can lead to thromboembolism.5
of the West of England, Coldharbour Lane, Bristol BS16 1QY, UK. E-mail: tony.
killard@uwe.ac.uk

Mrs Termeh Ahmadraji is a Prof. Tony Killard received his


postgraduate student in the BA(Mod) Honours in Natural
Faculty of Health and Life Sciences (Microbiology) at
Sciences at the University of Trinity College, Dublin in 1993
West of England undertaking and his PhD in Biotechnology at
her PhD in the development of Dublin City University (DCU) in
biosensors using inkjet printing 1998. He became Principal
technologies. She received her Investigator at the Biomedical
MSc in Analytical Chemistry in Diagnostics Institute, DCU in
2003 and worked in the phar- 2005 and was appointed to the
maceutical industry as a senior Chair of Biomedical Sciences at
scientic ocer before taking up the University of the West of
her studentship in 2011. She has England in January 2011. He
been a member of the Royal was also appointed Adjunct Professor at the Biomedical Diagnos-
Society of Chemistry since 2009. tics Institute in October 2011. His research is focussed on the
application of advanced materials and processing methodologies
to the fabrication of sensors, biosensors and biomedical diagnostic
devices. Tony is a Member of the Royal Society of Chemistry.

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Fig. 1 Chemical structure of (a) cholesterol, and (b) cholesteryl ester.6

Cholesterol (including cholesteryl esters), phospholipids cholesterol in the blood. The lipid cores of HDL and LDL
(PLs), and triglycerides (TGs) are three major types of lipid contain cholesteryl esters (CEs) and TGs surrounded by PLs,
present in the plasma. Cholesterol [(3b)-cholest-5-en-3-ol] is by unesteried cholesterol and specialized proteins known as
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far the most abundant member of a family of polycyclic apolipoproteins (Fig. 2). The CEs are enriched in linoleate,
compounds known as sterols. Cholesterol in plasma lipoprotein reecting their biosynthetic origin. Apolipoproteins are
can be found in the free form, esteried to long-chain fatty acids amphipathic in nature which can interact with lipid moieties of
(cholesteryl esters), and in other covalent and non-covalent lipoproteins and the aqueous environment and are specialized
linkages in animal tissues.7 The chemical structures of choles- to facilitate several biochemical steps associated with plasma
terol and cholesteryl ester are shown in Fig. 1. lipid metabolism.1113 Plasma apolipoprotein can be classied
Since lipids are not readily soluble in water, only small as the non-exchangeable apolipoproteins (e.g. apo B-100) and
amounts are present as unesteried cholesterol. To allow the exchangeable apolipoproteins (e.g. apo A-I, apo A-II).12
adequate transport of cholesterol and other lipids, lipoproteins LDL particles with a density range between 1.019 and 1.063 kg
form a coat around the lipids in order to suspend them in the L1 carry 6070% of the total serum cholesterol. A single apoli-
plasma. Lipoproteins are particles composed of lipid and protein poprotein, apo B-100 is the only protein component of LDL,
which are held together with noncovalent bonds. They consist of a which is highly insoluble in aqueous solution and is the largest
nonpolar lipid core of mainly cholesteryl ester and triacylglycerols monomeric protein known.12 Since apo B-100 is highly insoluble
and an outer layer of phospholipids, unesteried cholesterol and in aqueous solution, it remains with the lipoprotein particle
proteins (Fig. 2). The function of the lipoprotein particle is to throughout its metabolism.14 Fig. 3 is a schematic of the LDL
transport lipids such as cholesterol or triglycerides around the consensus model summarizing the proposed organization of
body via the blood stream. Based on the relative densities of these lipid: Hydrophobic core lipid including cholesterol ester and
species, chylomicron (CM), very low-density lipoprotein (VLDL), TGs, hydrophilic shell of phospholipid and unesteried choles-
low-density lipoprotein (LDL) and high-density lipoprotein (HDL) terol.12 LDL is the major atherogenic lipoprotein and has long
are the four major categories of lipoprotein.4 been identied by the National Cholesterol Education Program
Lipoproteins have unique physical and chemical character- (NCEP) as the primary target of cholesterol lowering therapy. The
istics, particularly with respect to their relative amount of lipids, importance of reducing the risk of coronary heart disease (CHD)
proteinlipid ratio and specic protein species present (Table by lowering LDL-C has been shown by clinical trials.15,16
1). Since lipoproteins vary in size and density, centrifugation HDL is the smallest lipoprotein, which normally carries 20
techniques have been used to separate them and distinguish 30% of the total serum cholesterol (HDL-C). Apo A-I and apo A-II
them from each other. LDL and HDL are the two major lipo- are the two major apolipoproteins of HDL. They are both clas-
proteins found in humans, and are responsible for carrying sied as exchangeable amphipathic apolipoproteins and are
soluble in aqueous solutions. All the apolipoproteins, other
than apo B-100, have a helical structure with a hydrophobic
and a hydrophilic domain. The hydrophobic domain of the

Fig. 2 General structure of lipoproteins. Adapted from Grin (2009).10 Fig. 3 LDL consensus model.

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Table 1 Classication of lipoproteinsa

Free Cholesteryl
Classb Density (kg L1) Diameter (nm) Protein (%) cholesterol (%) ester (%) Phospholipids (%) Triglycerides (%)

HDL 1.0631.21 815 33 7 40 46 6


LDL 1.0191.063 1824 25 11 50 29 10
VLDL 0.951.006 3052 10 7 18 20 55
CM <0.95 801200 <2 2 3 8 85
a
Adapted from Garrett and Grisham (1995),8 Rifai et al. (2001)9 and Grin (2009).10 b HDL: high density lipoprotein; LDL: low density lipoprotein;
VLDL: very low density lipoprotein; CM: chylomicron.
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apolipoprotein interacts with the lipid, while the hydrophilic Table 2 ATP III Classication of total cholesterol, LDL Cholesterol and HDL
domain orientates itself towards the aqueous phase.15 The main cholesterol. Reproduced from ATP III report (2001)3

protein component of HDL is apo A-I, of which 70% is synthesized


Analyte Concentration (mg dL1) Classication
within the liver and the rest in the intestine.7 Fig. 4 illustrates that
nascent HDL (HDL3) is secreted by the liver and intestines and is Total cholesterol <200 Desirable
transformed into mature HDL2 by the action of the lecithin- 20029 Borderline high
cholesterol acyltransferase (LCAT). HDL3 is discoid in structure $240 High
LDL cholesterol <100 Optimal
and contains apo A-I, phospholipids and free cholesterol while 100129 Near or above optimal
HDL2 is round, mature and contains esteried cholesterol.17 130159 Borderline high
Although HDL-C levels are inversely correlated with the risk 160189 High
of CHD,18 the value of treating low HDL-C is not as well estab- $190 Very high
lished as treating high LDL-C. Most treatment options for HDL cholesterol <40 Low
$60 High
lowering high LDL-C levels such as physical exercise, weight
loss and even some of the cholesterol lowering drugs, have also
demonstrated a benecial eect on HDL-C concentration.15,19 Importance of standardisation of
measurement for HDL-C and LDL-C
Since low HDL-C and high LDL-C levels are linked to increased
risk of heart attack,4,20 the importance of accurate measurement
of both HDL-C and LDL-C has been emphasized by the National
Cholesterol Education Program (NCEP).3,15,2123 The NCEP is a
program managed by the US National Heart, Lung and Blood
Institute which established the laboratory standardisation
panel on blood cholesterol measurement in order to assess the
reliability of cholesterol measurement in clinical laboratories
and improve the precision and accuracy of cholesterol testing.9
The main reason for standardisation is to ensure the agreement
of reported results across measurement systems, laboratories
and over time.24
Table 2 shows the classication of serum total cholesterol
(TC), LDL and HDL as summarised in the third report of the
expert panel on detection, evaluation, and treatment of high
Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP
III) presenting the NCEP's updated recommendations for
cholesterol testing and management.3 Based on the clinical
need to reliably categorise patients, the NCEP established
analytical performance goals for measurement of the total
cholesterol, HDL-C and LDL-C (Table 3).21,25

The development of routine methods for the


measurement of HDL and LDL cholesterol
Given the fact that lipoproteins are dened by their density,
one of the rst separation methods used to dierentiate
Fig. 4 The metabolic origins of HDL. With permission from Rye and Barter (2012).17 between HDL-C and LDL-C and other lipoproteins was

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Table 3 NCEP criteria for TC, HDL-C and LDL-C testing. Reproduced from ATP III secondary reference method for HDL-C measurement.21,24 There
report (2001) (ref. 3)a are three key steps to this method:
1. Ultracentrifugation at a density of 1.006 kg L1 to isolate
Analyte Inaccuracy Imprecision Total error
HDL and LDL from other lipoproteins.
TC #3% RM CV # 3% #8.9% 2. Selective precipitation of LDL with heparin/MnCl2.
HDL-C #5% RM SD # 1.7 AT (<42 mg dL1) #13% 3. Analysis of cholesterol in the HDL (supernatant) using the
CV # 4.0% at ($42 mg dL1) Abell-Kendall assay.9
LDL-C #4% RM CV # 4% #12%
Since there are only a few laboratories capable of performing
a
RM reference value assigned by CDC reference measurement the ultracentrifugation steps necessary in the CDC method, and
procedure, CV coecient of variation, SD standard deviation.
due to the high volume (greater than 5.0 mL) of sample
required, the Cholesterol Reference Method Laboratory
Network (CRMLN) also developed the Designated Comparison
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ultracentrifugation. However, since ultracentrifugation Method (DCM) based on a modied dextran sulphate proce-
methods are tedious, time consuming and do not easily achieve dure.36 This method uses 50 kDa dextran sulphate with MnCl2
complete and reproducible recovery, this approach is not for the precipitation of non-HDL, followed by measurement of
considered practical for use in clinical laboratories.9,15,19,26 the cholesterol in the supernatant by the CDC reference
However, ultracentrifugation is still considered as the basis of method. Other than reference methods based on ultracentri-
reference methods for measuring HDL and LDL choles- fugation, laboratory based tests using electrophoresis, chro-
terol.21,24,25,27 Since lipoproteins are a heterogeneous mixture of matography and spectrophotometry have been developed.
lipids and proteins which are not strictly dened, a signicant
overlap can exist in the physical properties of the major lipo- Electrophoresis
protein classes. Therefore, a primary reference method for HDL-
C and LDL-C measurement has not been developed.24 The most Due to the dierences in the size and charge of various lipo-
common approach used to determine LDL-C in the clinical proteins, isolation can be also achieved using electrophoresis
laboratory is the Friedewald calculation.16,28 The principle of the techniques, with visualization achieved using lipophilic dyes.19
Friedewald calculation is as follows: However, due to the fact that the lipophilic dyes are not specic
1. TC is distributed among the three major lipoprotein for a class of lipid such as cholesterol, TGs or PLs, these tech-
classes (HDL, LDL and VLDL). niques cannot be used for quantitative analysis, but can be used
2. VLDL carries most of the circulating TGs and therefore for qualitative analysis of lipoproteins.9,37,38 Visual presentation
VLDL-cholesterol (VLDL-C) can be estimated reasonably well is a distinct advantage of the electrophoretic methods facili-
from measured total TGs (TG/5 for mg dL1 or TG/2.2 for mM tating observation of atypical lipoproteins. For the routine
units). clinical laboratory, both ultracentrifugation and electrophoresis
3. LDL-C is then calculated as: have disadvantages especially when the workload is high.
In the last decade, there has been signicant progress in the
TG 
LDL-C TC  HDL-C  mg dL1 (1) development of microsystems applied to separation techniques
5 such as capillary electrophoresis.39 Ruecha et al. (2011) have
TG proposed a method for rapid detection of cholesterol using
LDL-C TC  HDL-C  mM (2) poly(dimethylsiloxane) microchip capillary electrophoresis
2:22
(PDMS MCE) based on the coupling of enzymatic assays and
This method is the most commonly used method in the electrochemical detection.40 Such techniques, could, in the
clinical laboratory and in large scale studies. Although the future, have the potential for selective determination of HDL-C
Friedewald method is widely used, the well-known limitation of and LDL-C at the point of care.
this method2933 increases the interest in improving the accu-
racy of LDL-C estimated by this equation.34 The Centers for Chromatography
Disease Control and Prevention (CDC) use a reference method
(RM) based on the Lipid Research Clinic's (LRC) beta-quanti- A variety of HPLC methods have been used to separate lipo-
cation procedure (BQ) for measuring LDL-cholesterol.9,35 In this proteins such as HDL, LDL, VLDL and CM, but this has been
method an aliquot of plasma is ultracentrifuged at density impeded by the poor stability of the columns used for separa-
1.006 kg L1 for at least 18 h at 105 000g to accumulate the tion.19,26 Even improved HPLC techniques which separate serum
VLDL as a oating layer. The amount of LDL-C is then calcu- lipoproteins based on their size using two connected columns
lated using eqn (3):9,16,26 with subsequent determination of cholesterol concentration
using an online enzymatic reaction cannot be used in the
LDL-C [d 1.006 kg L1 bottom fraction cholesterol routine clinical laboratory.4144
 HDL-C] (3) Recently Dong et al. (2011) have established a new method
for determination of HDL and LDL cholesterol using ultracen-
Accuracy in the HDL-C measurement has also been impor- trifugation and HPLC.45,46 Ultracentrifugation is used to sepa-
tant for the calculation of LDL-C using the Friedewald formula. rate HDL and LDL subfractions and Lipoprotein (a). Cholesterol
As recommended by NCEP, the CDC method is the current levels in the ultracentrifugal bottom fractions were analyzed by

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HPLC.46 While this method requires substantially less specimen not yet been fully elucidated.52 However, it is important to
volume when compared to other separation methods, it still consider the interaction between negatively charged groups on
requires the use of ultracentrifugation which is not applicable the polyanions and positively charged groups on the protein
to clinical measurement. moieties of the lipoproteins.53 Divalent metal ions interact with
negatively charged groups (such as phospholipids) on the
lipoproteins to facilitate formation of insoluble complexes.52,53
Spectrophotometry
The larger, more lipid-rich lipoproteins such as VLDL and LDL,
Due to its widespread adoption and simple methodology, many form insoluble complexes more readily than the smaller,
spectrophotometric methods have been developed to measure protein-rich HDL. The insoluble complexes may either remain
HDL-C and LDL-C. Initially, cholesterol was measured using suspended in the solution or oat to the surface in the presence
non-enzymatic spectrophotometry in the form of the Lie- of high concentrations of TG-rich lipoproteins. HeparinMn2+
bermannBurchard (LB) and KillaniZak assays.47 The LB has been a popular polyanion/divalent ion combination which
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reaction is performed in an acetic acidsulphuric acidacetic has been used to assign target values to reference materials.54
anhydride medium based on the fact that cholesterol reacts Since commercial heparin showed some inconsistency in its
with various strong acids of the Bronsted and Lewis types to properties for routine use, dextran sulphateMg2+ (50 kDa),52
yield coloured products. The KillaniZak assay was based on phosphotungstic acidMg2+ (ref. 55) and polyethylene glycol
direct treatment of the serum with a reagent composed of ferric (PEG)56 have been used as alternatives.
chloride dissolved in a glacial acetic acidsulphuric acid LDL particles can also be precipitated using certain reagents.
mixture.48 However, poor specicity, instability of the colori- The amount of LDL-C is determined by subtracting the choles-
metric reagent, and standardization diculties were some of terol measured in the supernatant from the total cholesterol.
the disadvantages of this method.49 The selectivity of spectro- Alternatively, the precipitate could be dissolved to measure the
photometric methods was improved signicantly by using level of LDL-C directly.26 A number of reagent formulations have
enzymes such as cholesterol esterase (ChEs), cholesterol been used for the selective precipitation of LDL-C including:
oxidase (ChOx) and horseradish peroxidase (HRP) (Fig. 5).50 heparin at pH 5.12 in sodium citrate buer; polyvinyl sulphate
Where 4AAP is 4-aminoantipyrine and Trinder's dye is an (PVS) in EDTA; PEG methyl ether; unspecied amphipathic
enhancer such as phenol. Measuring the amount of O2 polymers in imidazole buer, at pH 6.10.57 These precipitation
consumed or the levels of H2O2 produced are the preferred methods did not show noticeable advantages in precision and
methods of quantifying cholesterol spectrophotometrically. accuracy compared to the Friedewald calculation.
Due to the consumption of oxygen by other substances such as
ascorbic acid in clinical samples, any method measuring the
amount of oxygen consumed in Fig. 5 is not accurate.2 There- Homogeneous methods
fore, measuring the amount of H2O2 produced was found to be Homogeneous assays were a major step forward in improving
a more accurate method of quantifying blood total choles- the precision of earlier precipitation methods. Full automation
terol.50,51 In this method, the H2O2 generated in the presence of eliminated manual pipetting, o-line pre-treatment, centrifu-
4AAP, phenol and HRP forms a quinoneimine dye, which can be gation and separation steps and improved assay precision, in
measured at 500 nm by spectrophotometry. line with recommended NCEP criteria. The development of such
For the selective measurement of HDL-C or LDL-C, two assays has been an area of intense commercial research and
additional aspects of the assay need to be employed. Firstly, the development dominated by several Japanese companies
enzymes must gain eective access to the cholesterol associated including Kyowa Medex, Seikisui Medical (formerly Daiichi Pure
with the lipoprotein fraction. Secondly, the enzymes must also Chemicals Company), Deneka Seiken Co., Kokusai or Sysmex
only gain access to the cholesterol from the specic lipoprotein International Reagents (formerly International Reagents
fraction to be measured and be preventing from catalysing Corporation, IRC), Wako Chemicals, UMA and Serotec.58 The
cholesterol in other fractions. In the following sections, some of precise mechanisms involved in the interaction between the
the approaches that have been used for measuring HDL-C and lipoproteins and the assay reagents used in these assays remain
LDL-C will be reviewed. unclear.59 Fig. 6 illustrates a generalised approach to the selec-
tive detection of HDL-C in the presence of other lipoproteins
Selective methods of HDL and LDL using the homogeneous principle. A brief description of the
cholesterol measurement principles of each of the homogeneous HDL-C assay methodol-
ogies is given in the following section and their reaction mech-
Chemical precipitation methods anisms and performance characteristics summarised in Table 4.
In chemical precipitation methods, lipoproteins other than the In their review, Warnick et al. (2001) described the methods
target, e.g., HDL-C are aggregated and rendered insoluble using of Kyowa Medex, Daiichi, Deneka, International Reagents
polyanions in combination with divalent cations which can Corporation (IRC) and Wako for HDL-C in detail and compared
then be sedimented by low-speed centrifugation, while HDL them with conventional assay methods.19 The authors reported
remains soluble.9 The supernatant containing HDL-C can then that all ve methods demonstrated acceptable accuracy, preci-
be recovered for cholesterol analysis. The specic mechanism of sion and total error by meeting the NCEP criteria, making them
lipoprotein precipitation by polyanions and divalent cations has suitable for clinical application.

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Fig. 5 Spectrophotometric measurement of cholesteryl ester and cholesterol using cholesterol esterase (ChEs) and cholesterol oxidase (ChOx). The generation of H2O2
is detected using horseradish peroxidase (HRP) in the presence of 4-aminoantipyrine (4-APP) and phenol, generating a quinoneimine dye which is measured at 500 nm.

IRC was the rst to publish a report of a HDL-C fully auto- because of the amphiphilic properties of the attached PEG
matable homogeneous assay based on an immunological molecules.62 Therefore, HDL should be more susceptible to the
separation method in 1994. Based on this method, CM, VLDL modied enzyme than LDL, explaining the observed dierences
and LDL were rst aggregated using a reagent containing PEG in reactivities of cholesterol moieties of the lipoprotein frac-
and then protected with antibodies to apo B and apo C. In the tions. H2O2 generated from the enzymatic reaction is measured
next step, unprotected HDL-C underwent enzymatic reaction as spectrophotometrically.19,62,63 This method was evaluated in
described in Fig. 5.19 In the nal step, guanidine salts were used several studies including comparison with RM and DCM
to stop the enzymatic reaction and clear the reaction mixture. methods, which showed correlations of 0.993 and 0.996,
The nal absorbance was measured at 600 and 700 nm.9,19 In respectively.15
spite of the fact that this assay showed reasonable precision, Daiichi developed a homogeneous assay for HDL-C which
accuracy and specicity, the addition of four dierent reagents employed a synthetic polymer together with a polyanion to
limited its application to a small number of automated block the non-HDL lipoproteins.19 Cholesterol in HDL was then
analyzers.60 Later on Kokusai (formerly IRC) developed a new exposed to the enzymes in the presence of a selective detergent
reagent containing calixarene to produce a soluble complex of which gives specicity for HDL-C.64,65 Kondo et al. (1999) visu-
non-HDLcalixarene.61 alized the formation of HDLpolymer complexes aer the
In 1995, Kyowa Medex reported a homogeneous assay for addition of polymer and polyanion (the rst reaction) using
HDL-C. Based on this method, the combination of PEG-modi- electron microscopy. This showed that this complex breaks
ed enzymes with a-cyclodextrin sulphate provided selectivity down in the presence of a detergent in the second reaction. It
for the determination of HDL C in serum in the presence of a also showed that the polyanion in reagent 1 (phosphotungstate)
small amount of dextran sulphate with no need for precipita- caused the aggregation of almost all lipoprotein. However, the
tion of lipoprotein aggregates. PEG-modied ChEs and ChOx exact roles of the polyanion and synthetic polymer remain
showed selective catalytic activity toward lipoprotein fractions. unknown.59 Commercial reagent sets included two reagent
The reactivity increased in the order LDL < VLDL z CM < additions; the rst with the polyanion and polymer blocking
HDL.62 Although the mechanism for the selectivity of the agents and the second with detergent, enzymes, and substrates.
modied enzymes towards the lipoprotein fractions is not clear, The specicity and analytical performance of this method was
it is suggested that the modied enzymes may be able to investigated and published in several studies.59,6668
recognize dierences in hydrated density, net charge, or size of Kurosaki et al. (2009) have reported that with the Daiichi
the various lipoprotein fractions. Size-exclusion chromatog- method, free cholesterol in serum was eliminated in the rst
raphy revealed that PEG-modied ChEs breaks up the lipopro- reaction, and free cholesterol in HDL was not measured.69 Later
tein particles more eectively than the native enzyme, probably on in 2009, Daiichi published a patent regarding its modied

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Fig. 6 Generalised homogeneous assay methodology for the selective determination of HDL-C. A blocking reagent selectively prevents access of a specic surfactant
to the non-HDL lipoproteins. Addition of the surfactant selectively solubilises the HDL, allowing access to cholesterol esterase (ChEs) and cholesterol oxidase (ChOx). The
generated H2O2 can then be measured in the conventional manner.

method.70 In a rst reaction, free cholesterol on the surface of surfactant to solubilise HDL-C, an inhibitor of catalase, 4-AAP
only LDL and VLDL reacts with ChEs and ChOx. The H2O2 and N-(2 hydroxy-3sulfopropyl)-3,5-dimethoxyaniline (HDAOS),
produced in the reaction is eliminated by peroxidase; thus no colour is developed.19,74
colour formation occurs in response to free cholesterol. In the Finally according to the phosphate complex inhibition
second step, a special detergent causes only HDL to be dissolved method introduced by Serotec and UMA, HDL-C in the presence
to allow the reaction between HDL-C and the enzyme. As a of a detergent and phosphate compound undergoes an enzy-
detergent, a polyoxyethylene derivative such as Emulgen B-66 or matic reaction.61
Emulgen-90 (Kao Corporation, Japan), which directly hydrolyzes According to the homogeneous method for LDL-C, lipopro-
the HDL particles can be used.7072 Using this methodology, teins other than LDL such as VLDL, HDL and CM are removed in
HDL-C could be conveniently quantied without resort to the the rst step using the rst reagent described by each method. In
use of polyanions as in their original method. the second stage, LDL-cholesterol undergoes an enzymatic reac-
Wako Chemicals introduced a more convenient immu- tion to produce hydrogen peroxide which is measured colori-
noinhibition homogeneous assay using anti human-b-lipopro- metrically.26,33 Various physicochemical combinations of
teins to produce soluble complexes of CM, VLDL and LDL with surfactants, polymeric complexes and specic binding molecules
no reaction with enzymes involved in subsequent enzymatic were also used in establishing homogeneous assays to selectively
cholesterol reaction. Only the cholesterol content of HDL is measure LDL-C.75 Although the mechanism that confers selec-
measured in the presence of enzymes in the second reagent.66,73 tivity to LDL-C from a specic surfactant is also not well under-
The HDL-C method developed by Deneka Seiken Co. was stood, the same general mechanism is thought to apply as for
based on the fact that non-HDL-C selectively reacts with the HDL-C in that the surfactant may be able to distinguish dier-
ChEs and ChOx in the rst step without producing any colour. ences in hydrated density, net charge, or size of the various
H2O2 produced in this step is scavenged by the enzyme catalase. lipoprotein fractions.76,77 A brief description of the principles of
In the next step, in the presence of a reagent containing a each of the homogeneous LDL-C assay methodologies is given in

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Table 4 Schematic reaction mechanism for HDL-C Assay kits and their performance. Adapted from Nakamura et al. (2006) (ref. 61)a

Assay kits Performance and others

Daiichi (accelerator selective detergent method)


First step: Dynamic range: 1.5150 mg dL1
1. Non-HDLs + synthetic polymers + polyanions / soluble Not measurable in presence of abnormal lipoprotein caused by sever
complexes of non-HDL liver dysfunction.
Second step: No interference by TG value at up to 1500 mg dL1
2. HDL-C + selective detergent + ChEs + ChOx / cholestenone + fatty No interference by hemoglobin at up to 500 mg dL1
acid + H2O2
3. H2O2 + 4AAP/peroxidase + DSBmT / color development No interference by bilirubin at up to 50 mg dL1
Recommended sample storage: one-week under refrigeration,
sample can be frozen-thawed only once.
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Kyowa Medex (modied enzymatic method)


First step: Dynamic range: 0120 mg dL1
1. Non-HDLs + a-cyclodextrin + MgCl / soluble complexes of non- No interference by TG value at up to 1200 mg dL1
HDL
Second step: No interference by hemoglobin at up to 1200 mg dL1
2. HDL-C + PEG modied ChEs and ChOx / cholestenone + fatty No interference by bilirubin at up to 30 mg dL1 (conjugated form)
acid + H2O2 and 70 mg dL1 free form
3. H2O2 + 4AAP/peroxidase + HDAOS / color development Recommended sample storage: one-week under refrigeration,
sample can be frozen-thawed only once.

Kokusai or Sysmex (calixarene complex method)


First step: Dynamic range: 1.5100 mg dL1
1. Non-HDLs + calixarene / non-HDLcalixarene soluble complex Negative predictive value or the samples of liver dysfunction and
positive value in presence of LDL fractions and apo E-rich serum
Second step: No interference by TG value at up to 1500 mg dL1
2. HDL-C + ChEs + ChOx + hydrazine + b-NAD / cholestenone No interference by hemoglobin at up to 500 mg dL1
hydrazone + b-NADH
+ ChEs from Chromobacterium viscosum cannot react to the non- No interference by bilirubin at up to 20 mg dL1
HDLcalixarene soluble complex. Recommended sample storage: three days under refrigeration,
sample can be frozen only once at 80  C.

Wako (immunoinhibition method)


First step: Dynamic range: 1180 mg dL1
1. Non-HDLs + anti human-b-lipoprotein / soluble complexes of Positive value in presence of LDL, VLDL and apo E-rich HDL
non-HDL
Second step: No interference by TG value at up to 1200 mg dL1
2. HDL-C + ChEs + ChOx / cholestenone + fatty acid + H2O2 No interference by hemoglobin at up to 500 mg dL1
3. H2O2 + 4AAP/peroxidase + F-DAOS / color development No interference by bilirubin at up to 50 mg dL1
Recommended sample storage: four days under refrigeration,
sample can be frozen-thawed only once.

Serotec and UMA (phosphate complex inhibition method)


First step: Dynamic range: Up to 200 mg dL1
1. HDL-C + detergent and IP compound (inorganic/organic) + ChEs Positive value in presence of VLDL fractions
/ free cholesterol + fatty acid
Second step: No interference by TG value at up to 1100 mg dL1
2. Free cholesterol + ChOx / cholestenone + fatty acid + H2O2 No interference by hemoglobin at up to 500 mg dL1
3. H2O2 + 4AAP/peroxidase + HDAOS / color development No interference by free bilirubin at up to 40 mg dL1 and 6% in the
presence of 40 mg dL1 conjugated form
Recommended sample storage: one-week under refrigeration,
sample can be frozen-thawed only once at 20  C or lower.

Deneka Seiken (elimination method)


First step: Dynamic range: 1150 mg dL1
1. Non-HDL-C + ChEs + ChOx / cholestenone + fatty acid + H2O2 No interference by TG value at up to 1500 mg dL1
2. H2O2 + catalase / 2H2O + O2 No interference by hemoglobin at up to 500 mg dL1
Second step: No interference by bilirubin at up to 30 mg dL1
3. HDL-C + detergent + ChEs + ChOx / cholestenone + fatty acid + Recommended sample storage: one-week under refrigeration,
H2O2 sample can be frozen-thawed only once.
4. H2O2 + 4AAP/peroxidase + HDAOS / color development
a
4AAP: 4-aminoantipyrine, DSBmT: N,N-bis-(4-sulphobutyl)-m-toluidine, HDAOS: N-(2-hydroxy-3-sulphopropyl)-3,5-dimethoxyaniline, F-DAOS: N-
Ethyl-N-(2-hydroxy-3-sulphopropyl)-3,5-dimethoxy-4-uoroaniline.

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Analytical Methods Critical Review

the following section and their reaction mechanisms and viscosum), ChOx and hydrazine, cholesterol in the lipoproteins
performance characteristics summarised in Table 5. other than LDL converts to cholestenone hydrazone. Finally the
Nauck et al. (2002) have reviewed homogeneous methods for LDL-calixarene complex is broken down aer the addition
LDL-C and compared them with conventional assay deoxycholate, ChEs, ChOx and NAD, yielding cholestenone and
methods.19,26 The rst LDL-C homogeneous assay was oered by NADH. NADH is then measured spectrophotometrically.26,80,81
Kyowa Medex in 1998 and distributed by Roche Diagnostics.76 Finally according to the Serotec and UMA methodology, LDL-C
To provide the required selectivity, the combination of poly- in presence of a selective detergent, phosphate compound and
oxyethylenepolyoxypropylene (POEPOP) block co-polymer cholesterol esterase produce free cholesterol. The free choles-
with a-cyclodextrin sulfate was employed for the determination terol is determined according to Fig. 5.61
of LDL-C, followed by reaction with ChEs and ChOx. MgCl2 and A multicentre evaluation of ve direct assays of LDL-C
a-cyclodextrin sulphate are rst used as a quencher for CMs and (Daiichi, Denka Seiken, Kyowa and Wako) was performed using
VLDL-C and the POEPOP acts as a quencher for HDL-C.62,76 45 serum samples (TG below 3.1 mmol L1) in eight laboratories
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Due to the limited specicity of POEPOP toward LDL-C, the using dierent analysers.82 Inter-laboratory reproducibility was
LDL-C is selectively solubilised into mixed micelles and enzy- improved markedly compared to the Friedewald calculation for
matic reaction occurs. The level of selectivity toward LDL-C is Daiichi, Kyowa and Wako. All the above mentioned methods
directly dependent on the molecular mass and hydrophobicity showed strong correlation in comparison with the BQ assay.
of the POP blocks.62,76 This method was not found to be su- Miller et al. (2010) have compared some of the commercially
ciently specic for LDL-C, since LDL is only partially recovered available homogeneous methods for measurement of HDL-C
and apo E-rich HDL and VLDL are not completely excluded.16,26 and LDL-C with the RM for accuracy and total error. Specicity
Daiichi reported a method employing non-ionic surfactant and imprecision were also estimated. Table 6 shows that 5 of 7
to solubilise all non-LDL lipoproteins.26 Hydrogen peroxide HDL-C homogeneous methods reached the 95% acceptance
enzymatically generated in this step is then catalysed by a HRP criteria for non-diseased individuals but deteriorated consid-
in the presence of 4-aminoantipyrene. No colour is produced in erably for the samples from the diseased group.
this step. A second specic detergent is used to solubilise LDL-C Only the Kyowa and Seikisui methods met total error goals
and generate hydrogen peroxide. The hydrogen peroxide in for measuring HDL-C in diseased individuals.58 None of the
presence of N,N0 -bis-(4-sulphobutyl)-m-toluidine disodium salt, LDL-C homogeneous methods met the criteria for the diseased
HRP and 4-aminoantipyrene then generates colour which is individuals and only four of them met the criteria for non-
proportional to the level of LDL-C. The method is linear up to diseased individuals.58
1000 mg dL1, with the detection limit of 0.4 mg dL1 and Iizuka et al. (2012) also compared homogeneous assay kits
seems to be aected by increased TGs and is not completely for HDL and LDL cholesterol.83 The aim was to clarify the
specic for LDL-C.16,26 commutability of currently used homogeneous assays to
The homogeneous LDL-C assay from Wako is based on rst measure HDL-C and LDL-C. It was shown that all of the above
protecting LDL-C selectively from enzymatic reaction in the mentioned HDL-C assay kits are commutable. Wako was the
presence of polyanions and amphoteric surfactants. As a result, only assay kit which showed discrepancy in the high bilirubin
lipoprotein cholesterols other than LDL-C undergo enzymatic samples. All the LDL-C assay kit results were aected by the
catalysis and generate hydrogen peroxide which is consumed by lipoprotein in the patient samples.83 Accuracy and precision
catalase. In the second step, a non-ionic surfactant as a de- issues for the measurement of LDL-C have been reviewed in
protection agent then enables the LDL-C to react with ChEs and several papers and the necessity of improving the accuracy of
ChOx to produce hydrogen peroxide. The colour yield from the LDL-C measurement has been emphasised.81,8489
reaction of hydrogen peroxide and Trinder's reagent and
4-aminoantipyrene is again measured spectrophotometrically.26
Total CVs at LDL-C concentrations between 103.4 and 219.6 mg Point of care testing (POCT) for HDL-C and LDL-C
dL1 were 1.2% and total error ranged from 2.6% to 5.6%.78 The In order to remove sample transport requirements, reduce
method was found linear up to 300 mg dL1 with the detection processing and assay times and facilitate near patient testing,
limit of 1.0 mg dL1.26 In spite of linearity issues and TG inter- point of care devices that measure HDL-C and LDL-C directly
ference, the assay seems to be relatively specic for LDL-C.75,78 are very attractive in biomedical diagnostics. In general, point of
Deneka Seiken reported a homogeneous LDL-C assay using a care testing needs relatively small volumes of whole blood
combination of two non-ionic surfactants (Emulgen B-66 and directly from a ngerstick and test results are available soon
Emulgen A-90) with a hydrophilelipophile balance (HLB) of aer sampling, which is highly advantageous in self-manage-
13.5 which can selectively remove non-LDL-C in the presence of ment of hypercholesterolemia. There is no requirement for
MgCl2. Based on this method, the reactivity of cholesterol in transportation of samples to a central laboratory which helps to
each lipoprotein depends on the HLB of the detergents.26,79 The reduce result turnaround time and transport costs. Earlier
evaluation of this assay has been very limited. However, avail- diagnosis and disease management as well as potential for
able data suggests that it has high specicity for LDL-C. improving patient satisfaction and cost-eectiveness are some
The method developed by IRC for LDL-C uses a calixarene as other advantages oered by POCT.9092
a detergent which converts LDL to an LDL-calixarene soluble A number of both professional use and consumer point of
complex. In the presence of ChEs (from Chromobacterium care devices for measurement of cholesterol are commercially

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Critical Review Analytical Methods

Table 5 Schematic reaction mechanism for LDL-C Assay kits and their performance. Adapted from Nakamura et al. (2006) (ref. 61)a

Assay kits Performance and others

Daiichi (liquid selective detergent method)


First step: Dynamic range: 1450 mg dL1
1. Surfactant 1 + ChEs/ChOx + CM, VLDL and HDL-C / No interference by TG value at up to 1500 mg dL1
cholestenone + fatty acid + H2O2
2. 2H2O2 + catalase / 2H2O + O2 No interference by hemoglobin at up to 500 mg dL1
Second step: No interference by bilirubin at up to 20 mg dL1
3. LDL-C + surfactant 2 + ChEs/ChOx/peroxidase + DSBmT / color Recommended sample storage: one-week at 4  C, sample can be
development frozen-thawed only once.

Kyowa Medex (selective solubilization method)


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First step: Dynamic range: 0550 mg dL1


1. Non-LDLs are blocked by surfactant and sugar compounds No interference by TG value at up to 1200 mg dL1
Second step: No interference by hemoglobin at up to 1500 mg dL1
2. LDL-C + surfactant + ChEs/ChOx / cholestenone + fatty acid + No interference by bilirubin at up to 39 mg dL1 (conjugated form)
H2O2 and 70 mg dL1 free form
3. H2O2 + 4AAP/peroxidase + HDAOS / color development Recommended sample storage: one-week under refrigeration,
sample can be frozen-thawed only once.

Kokusai or Sysmex (calixarene complex method)


First step: Dynamic range: 1350 mg dL1
1. LDL + calixarene / LDL-calixarene soluble complex Positive predictive value in the presence of LDL fractions, apo E-rich
HDL and samples of liver dysfunction
Second step: No interference by TG value at up to 1500 mg dL1
2. CM, VLDL and HDL-C + ChEs(1)/ChOx + Hydrazine / No interference by hemoglobin at up to 500 mg dL1
cholestenone hydrazone
+ ChEs (1) (from Chromobacterium), can not react with LDL- No interference by bilirubin at up to 20 mg dL1
calixarene soluble complex
3. LDL-calixarene soluble complex + ChEs(2)/ChOx + hydrazine + Recommended sample storage: three days under refrigeration,
b-NAD + deoxycholate / cholestenone hydrazone + b-NADH sample can be frozen only once at 80  C.
+ ChEs (2) (from Pseudomonas species)

Wako (enzyme selective protecting method)


First step: (elimination of non-LDL cholesterol) Dynamic range: 1.0400 mg dL1
1. LDL + protecting reagent / LDL-protecting reagent Positive predictive value in presence of VLDL fractions
2. CM, VLDL and HDL-C + ChEs/ChOx / H2O2 + Catalase / H2O No interference by TG value at up to 1000 mg dL1
Second step: No interference by hemoglobin at up to 500 mg dL1
3. LDL-protecting reagent / deprotecting reagent / LDL No interference by bilirubin at up to 50 mg dL1
4. LDL-C + ChEs/ChOx / cholestenone + H2O2 Recommended sample storage: one-week refrigeration, sample can
be frozen-thawed only once.
5. H2O2 + 4AAP/peroxidase + HDAOS / color development

Serotec and UMA (phosphate complex inhibition method)


First step: Dynamic range: Up to 500 mg dL1
1. LDL-C + detergent and IP compound (inorganic/organic) + ChEs Positive value in presence of VLDL and LDL fractions
/ free cholesterol + fatty acid
Second step: No interference by TG value at up to 1100 mg dL1
2. Free cholesterol + ChOx / cholestenone + fatty acid + H2O2 No interference by hemoglobin at up to 500 mg dL1
3. H2O2 + 4AAP/peroxidase + HDAOS / Color development No interference by bilirubin at up to 40 mg dL1
Recommended sample storage: one-week under refrigeration,
sample can be frozen-thawed only once at 20  C or lower.

Deneka Seiken (elimination method)


First step: Dynamic range: 1800 mg dL1
1. Non-LDL-C + surfactant combination 1 + ChEs/ChOx / No interference by TG value at up to 1000 mg dL1
cholestenone + fatty acid + H2O2
2. 2H2O2 + catalase / 2H2O + O2 No interference by hemoglobin at up to 500 mg dL1
Second step: No interference by bilirubin at up to 30 mg dL1
3. LDL-C + surfactant combination 2 + ChEs/ChOx / cholestenone + Recommended sample storage: one-week under refrigeration,
fatty acid + H2O2 sample can be frozen-thawed only once at 80  C.
4. H2O2 + 4AAP/peroxidase + HDAOS / color development
a
4AAP: 4-aminoantipyrine, DSBmT: N,N-bis-(4-sulphobutyl)-m-toluidine, HDAOS: N-(2-hydroxy-3-sulphopropyl)-3,5-dimethoxyaniline, F-DAOS: N-
Ethyl-N-(2-hydroxy-3-sulphopropyl)-3,5-dimethoxy-4-uoroaniline.

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Analytical Methods Critical Review

Table 6 Percentage total error results of a single measurement based on the


rst result (no replication) for ve homogeneous HDL-C and LDL-C assay
methods58

% HDL-C % HDL-C % LDL-C % LDL-C


results results results results
Method non-diseased diseased non-diseased diseased

Seikisui 100 96.4 100 91.1


Kyowa Medex 97.3 95.6 94.6 85.9
Deneka 100 92.7 89.2 85.2
Wako 100 74.5 97.3 87.4
Sysmex 100 89.8 86.5 71.9
UMA 91.9 83.9 97.3 75.6
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Serotec 94.6 86.9 97.3 53.3

available. The Cardiocheck PA and Cholestech LDX are two


systems that support the UK NHS health check vascular risk
assessment.93 Cardiocheck PA is based on a spectrophotometric
method and the measurement of the light reected o a
disposable test strip that has changed colour aer applying
blood sample. The analyzer converts this reading into an HDL
result and displays it.94,95 The Cholestech LDX system combines
the enzymatic methodology and solid-phase technology to
measure the quantity of TC, HDL-C, TGs, glucose, and others in
the blood (capillary or venous), serum or plasma. The sample is
applied to a Cholestech LDX cassette (Fig. 7). The cassette is
then placed into the Cholestech LDX analyzer that can measure
Fig. 7 (a) The Cholestech LDX point-of-care cholesterol analyser. (b) The
the resultant colour by reectance photometry.96 The LDX uses Cholestech LDX assay cartridge.
the Friedewald equation to calculate LDL-C while the
Cardiocheck PA measures LDL-C directly. A comparison
between Cholestech LDX POC and hospital reference laboratory
validates the use of the Cholestech LDX analyser for point of cholesterol lends itself eectively to electrochemical measure-
care lipid measurements in clinical practice under well-trained ment as many of the transduction principles employed are
operators.97 A comparison between the performances of these transferrable, such as the use of electron transfer mediators or
two point-of-care analyzers and clinical diagnostic laboratory hydrogen peroxide to measure the oxidation of cholesterol.100106
methods for the measurement of TC, HDL-C and LDL-C has However, despite the growing importance of the selective
been reported.94,98 Both devices meet NCEP guidelines for all determination of LDL-C and HDL-C for monitoring and
analytes at two clinical cut-o points. Both of them were found managing hypercholesterolaemia, coupled with the suitability
to have acceptable performance, which oers healthcare of electrochemical assay methodologies to translate well to
professionals a rapid POC method for the measurement of cholesterol testing, there are still relatively few examples of
cholesterol in specic lipoproteins. Moreover, determination of electrochemical biosensors capable of the selective determina-
the accuracy and precision of TC, TG and HDL cholesterol tion of LDL-C and HDL-C.
measures by a nurse on capillary blood using the Cardiocheck Several sensor techniques such as quartz crystal microbal-
system suggested that this approach was appropriate for pre- ance (QCM), surface plasmon resonance (SPR), cyclic voltam-
dicting CHD risk and provided reliable fractionated lipid metry (CV) and electrochemical impedance spectroscopy (EIS)
information which was consistent with traditional clinical have been employed to measure LDL quantitatively or qualita-
chemistry platforms.99 The evolution of point of care tests from tively.107 Piezoelectric devices have been extensively investigated
professional use instruments towards low cost, consumer as the basis for sensing due to their small size, small sample
diagnostics has been exemplied by the development of glucose requirements and high sensitivity.108 A piezoelectric LDL
biosensors. The progression from optical to electrochemical biosensor was developed which was based on capturing and
measurement methods is a natural evolution for many diag- detecting apo B-100 using interactions between its lysine rich
nostic devices as they progress from laboratory tests typically residues and immobilised components of the extracellular
based on spectrophotometry, to electrochemical devices which matrix such as collagens and proteoglycans.107,109,110 However,
allow lower cost instrumentation and system simplication.72,73 this was used to explore potential interactions between LDL and
Cholesterol testing is also going through this evolution. Several the vasculature, rather than to quantify LDL-C levels In addi-
devices are available which can measure free cholesterol using tion, although QCM biosensors have been found to be very
disposable electrochemical test strips. As with glucose, useful as laboratory-based investigative tools, their cost has

3622 | Anal. Methods, 2013, 5, 36123625 This journal is The Royal Society of Chemistry 2013
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Critical Review Analytical Methods

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